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Crossing state lines in the Bible Belt for heroin

Drug users cross the Ohio-Kentucky border to get high, and overdose-prevention efforts follow

Editor's note: This is the second in a two-part series on naloxone, an anti-overdose serum, and how the difference in access from state to state has affected users. The first installment can be found here.

BELLEVUE, Ky. — Five short bridges across the Ohio River connect northern Kentucky to Cincinnati, the region’s metropolis. All day and night, cars and trucks whiz back and forth. Over the past decade, the bridges have facilitated a different kind of traffic: black-market painkillers like oxycodone and Percocet and heroin sold in small plastic bags.

Until he entered detox a few months ago, 26-year-old Kentuckian Justin Spradlin crossed the river nearly every day to buy heroin. His mornings were a scramble to arrange a meeting with a dealer and get money for dope. Over time, he sold his mother’s wedding ring, used brass knuckles to rob passersby and prostituted his girlfriend, Heather, also an addict. “I sold her to 10 dope boys one night,” he said. “One gram each.”

Last July, as they shared a needle in his car, Heather collapsed and turned bluish gray — a sign of overdose. Spradlin panicked. He poured water on her and hit her in the face. She woke up screaming. “We didn’t have Narcan when I was shooting,” he said, referring to the brand name of naloxone, a serum that turns off the brain’s opiate receptor and triggers immediate withdrawal.

Though safe and easy to administer by injection or nasal spray, naloxone was, until recently, available only to paramedics and emergency-room physicians. But due to a surge in drug fatalities nationwide, this is changing fast.

In Ohio in 2012, an average of five people succumbed every day to unintentional overdoses, mostly from prescription painkillers. At Cincinnati’s Center for Chemical Addictions Treatment, said president Sandra L. Kuehn, about 72 percent of clients are addicted to opioids such as heroin and OxyContin, up from 10 percent a decade ago. Statistics are similarly grim in neighboring Kentucky, which saw nearly three overdose deaths every day in 2012. At the Brighton Recovery Center in Florence, according to director Anita Prater, 85 percent of the female patients are fighting heroin addiction.

The bridges connecting Cincinnati to northern Kentucky are a major thoroughfare for opiates.5chw4r7z / Flickr

To address this burgeoning opiate epidemic, Kentucky passed a law last year expanding prescription access to naloxone and granting amnesty to drug users who seek medical assistance. This March, Ohio lawmakers went further and authorized naloxone prescriptions for third parties not directly at risk of overdose, such as friends and parents. Now, first responders and concerned laypeople in almost 20 states may obtain naloxone by prescription or through local health organizations, and drug users can dial 911 without fear of drug-possession charges under “medical amnesty” laws. In the United States, about 10,000 people have been revived with naloxone since the mid-1990s.

Harm-reduction advocates have championed easier access to naloxone, and the state of Ohio came around. Two years ago, health officials launched Project DAWN, a pilot program combining various harm-reduction strategies. In Portsmouth, they educated active users, established a syringe exchange — a proven but controversial approach — and began stocking naloxone kits, in spite of regulations requiring individual prescriptions. The model has spread to cities such as Cleveland, Dayton and Columbus, and the state’s Veterans Affairs hospitals are now educating their patients about overdose risks. According to the health department, approximately 26 people in Ohio have already been revived with free, publicly funded naloxone administered by co-users, friends or family. Kentucky’s efforts are still nascent.

Judith Feinberg, professor of medicine at the University of Cincinnati, said: “The approaches have been really different in the two states. They passed a bill in Kentucky making naloxone more available, but it’s really been left up to individual physicians to do that. In Ohio, they passed a bill to make naloxone more available, but even before, the Ohio Department of Health had funded a number of programs.” One of them was Project DAWN.

But neither state has the resources or the political will to adequately fight the opiate epidemic, advocates say. As in most areas of the country, needle exchanges are rare. And despite the broad acceptance in principle of naloxone, Ohio and Kentucky lack the kind of “standing order” infrastructure that would empower community groups to distribute it without a physician on site.

The three-story Droege detox facility sits on a grassy hillock in Dayton, Kentucky. It could pass for an apartment complex or old folks’ home if not for the regular, gloomy stream of smokers wearing baggy turquoise scrubs. In April, a dozen men and women were coming off alcohol, crack cocaine and, above all, heroin.

Spradlin had checked himself in to Droege after more than a decade of regular drug use and recurring stints in jail. “My whole family is addicts,” he said. “When I was 13, I was smoking pot and selling drugs to my parents.” He sampled his mother’s pain pills and got hooked on prescription meds after an injury; then heroin came along. “It was cheaper,” he said, “and I liked the taste.”

“It’s an epidemic all over the country,” said “Nick” (who asked not to be identified by his real name), a quiet, raven-haired 25-year-old admitted to Droege in April. As a punk musician, Nick had witnessed heroin use across the country, from Portland, Oregon, to New Orleans and Buffalo, New York. He counted seven friends who had died from overdoses, and he had had a close call himself.

Lisa Roberts, a nurse at the Portsmouth City Health Department in Ohio, said, “In Appalachia, the pain-pill epidemic started about 15 years ago.” Sciota County, in southwestern Ohio, became an epicenter of overdoses, hepatitis C (spread through shared intravenous needles) and dubious pain clinics, aka “pill mills.” “We called it pharmageddon,” she said. “We had 10 pill mills owned by convicted felons and the highest narcotics-distribution rate [in the state]. So they changed the state law and got rid of pill mills, and four doctors got life sentences.” But shutting down the fraudulent providers did nothing to solve the underlying problem of opioid dependence. Oxycodone users transitioned to heroin, and overdose fatalities continued to rise.

Ordinary citizens mobilized in response to deaths in their schools and neighborhoods. “The community was recognizing there was a heroin problem, so [a local] pharmacy owner gave needles to anyone, $15 for 150 needles,” said Myles Dawson, a recovering heroin user who was twice revived by naloxone in small, tight-knit Marysville, Ohio. With access to clean needles, Dawson didn’t need to share with friends, eliminating his risk of transmitting hepatitis or HIV. He also benefited from sympathetic judges and police officers — including family friends — who steered him into treatment instead of jail. Once, when Dawson was driving while high and fell asleep at a stop sign, he was found by a detective who called his dad. “[The officer] said he needed to do rehab or jail, and [Myles] reluctantly agreed to rehab,” said Mindy Westlake, Dawson’s mother.

In Cincinnati, outreach worker Libby Harrison walks the streets of low-income, high-crime neighborhoods like Lower Price Hill. She picks up dirty needles, tells active users where to get naloxone and even gives her business card to drug dealers, hoping to speak with them about overdose prevention. (Some dealers sell clean needles along with heroin.) Recently, she and a staffer from Planned Parenthood were trying to find a neighborhood willing to host a mobile syringe-exchange unit: a van from which they could give out free needles, condoms and naloxone referrals to a local pharmacy.

In most of Kentucky, by contrast, harm reduction remains controversial — “on the other side of a four-letter word,” said Jason Merrick, a social-work student, director of People Advocating Recovery and recovering user. “It’s the Bible Belt,” he said. “A lot of people still think [drug addiction] is a moral malady, a decision people make.” But communities seem more open-minded near the Ohio border, where the ubiquity of addiction and overdose deaths has persuaded a coalition of locals, police, hospital workers and even business associations to support naloxone and explore the possibility of a needle exchange.

Merrick and a small team of doctors and other volunteers have set up two naloxone-prescription sites and conducted weekly outreach in northern Kentucky since April. They have provided overdose-rescue training and free naloxone kits (two doses, a syringe and nasal atomizers at a cost of $65) to about 50 opioid users and family members, with at least one reported “save.” They are also collecting used syringes and passing out educational materials on foot and in a ’67 Volkswagen microbus donated by the mother of an overdose victim. Merrick hopes to build support for future legislation that will allow community groups to freely distribute naloxone.

Naloxone can be injected or sprayed through a nasal atomizer.E. Tammy Kim / Al Jazeera America

The interstate nature of opiate abuse is as challenging to harm-reduction workers as to law enforcement. Former heroin users describe the Ohio-Kentucky border as porous but significant. “I went to Cincy every time,” Chris Otis, a recovering heroin user, said at the Grateful Life Center (GLC), a long-term men’s treatment facility in rural Erlanger, Kentucky. “It was easier and more reliable,” he said, and on days when he didn’t have money, “you can get testers [samples].” Heroin in hand, he’d park his car on a side street and inject the drug; the little baggies never made it across the bridge intact.

“Ohio is easier on people,” explained Peter Paskal, 29, a recovering heroin and OxyContin user who'd been accused of neglecting his children and entered GLC under court order. It was better, and faster, to face charges in Ohio, he said. “You can be in jail 60 to 70 days before your indictment in Kentucky.”

“That’s why dope boys won’t cross the river,” said 34-year-old Elwood “Woody” Ewing, a father and former Amazon employee who’d come to GLC as an alternative to jail. But according to Detective Ryan Markus of the Campbell County (Kentucky) Police Department, “drug traffickers” do drive south from Cincinnati into towns like Newport, Dayton and Bellevue, and he supports harsher criminal penalties to stanch this flow. The Kentucky legislature recently failed to pass a bill that would have expanded naloxone access but also reduced the threshold for a heroin felony; the harm-reduction community opposes such measures, which it sees as criminalizing addiction.

As law-enforcement officials attempt to map and respond to interstate drug traffic, health advocates are doing the same. Philanthropic funders and researchers are tackling opiate abuse as a regional issue, and outreach workers are coordinating their efforts across state lines.

Merrick, now five years clean, approaches harm reduction with evangelical fervor. Every weekend, he and his crew of volunteers hit the streets and country roads on the Kentucky side of the river, talking to community members one at a time and trying to reach homeless drug users — those least likely to attend a naloxone workshop. “If people begin to see and discuss the issue on a grassroots level, we feel they will be more likely to support protective measures in the future,” he explained. “People are still dying every day.”

Correction: This story was updated to correct the spelling of the towns in which Droege detox and its headquarters are located.